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Electronic health record implementation paper
Introduction to electronic health records
Impacts of electronic health records on the patients
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During the discussion with Dr. Martin of UMUC Family Clinic, he highlighted many goals he would like to achieve in order to improve his practice operation. Four of those goals and how an Electronic Health Record (EHR) system can help him with each goal will be discussed as listed below.
1. Improve the quality of care to his patient.
2. Reduce patient wait time.
3. Improve the financial management decisions of his practice.
4. Meet the legal and regulatory requirements for health care systems.
Improve the Quality of Care to His Patient
Dr. Martin introduction of EHR to his practice will definitely help to improve the quality of care his patients are receiving. The current system is so chaotic that patients have now accepted two hours of wait
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Martin’s practice is the unnecessary long patient wait time when they check in to his office. The current system of manually signing patient in and having to search through the file cabinet for patient record is time consuming. Dr. Martin with the Introduction of EHR system to his practice can significantly reduce the time patient spent in the waiting room and the paperwork burden of his front desk nurse. For instance, EHR system can help to reduce or eliminate altogether the refilling of information sheet at the front desk by returning patient as is the current practice at Dr. Martin’s office. Not only that, EHR through e-prescribing will eliminate the front desk duty of taking prescription refill requests thereby giving the staff more time to focus on other important task. Also due to rapid information sharing of EHR between providers and other healthcare system, the need of faxing or other manual means of sharing patient information will be reduced and thus reduced the administrative task of the front desk nurse so they have enough time for effective patient check in and reduce patient wait time. Finally, EHR allow for better follow-up. The EHR system can remind Dr. Martin to do a follow up with his patients and remind them of their appointments through email or text message and can offer health advice through this means thereby cutting down on unnecessary office visit (HealthIT.gov,
For years now, the healthcare system in the United States have managed patient’s health records through paper charting, this has since changed for the better with the introduction of an electronic medical record (EMR) system. This type of system has helped healthcare providers, hospitals and other ambulatory institutions extract data from a patient’s chart to help expedite clinical diagnosis and providing necessary care. Although this form of technology shows great promise, studies have shown that this system is just a foundation to the next evolution of health technology. The transformation of EMR to electronic heath record system (EHR) is the ultimate goal of the federal government.
Thus, reducing administrative work gives an opportunity to clinicians to spend more time with their patients. Through health informatics, some medical procedures can be automated, saving money for the health care budget. Research by Blumenthal and Tavenner (2010) states that, “The widespread use of electronic health records (EHRs) in the United States is inevitable. EHRs will improve caregivers' decisions and patients' outcomes. Once patients experience the benefits of this technology, they will demand nothing less from their providers.
This technology assist the nurse in confirming patients identify by confirming the patients’ dose, time and form of medication (Helmons, Wargel, & Daniels, 2009). Having an EHR also comes with a program that allows the medical staff to scan medications so medication errors can be prevented. According to Helmons, Wargel, and Daniels (2009) they conducted an observational study in two medical –surgical units one in the medical intensive care (ICU) and one in the surgical ICU. The researchers watched 386 nurses within the two hospitals use bar code scanning before they administrated patients’ medications. The results of the research found a 58 % decrease in medication errors between the two hospitals because of the EHR containing a bar code assisted medication administration
The goal of the program is to increase EHR adoption, improve quality, safety, reduce disparities, and improve public health (HMSA, 2012). The Meaningful Use program was set up for implementation in three stages over a five-year period. The first stage ended in 2012 and involved evaluating health trends, and finding out methods to engage patients and families in their own care. Stage two focuses on advanced data sharing, such as e-prescribing and electronic exchange of patient information between professionals. Stage three’s focus will be on outcomes, patient access to care and self-help care tools for patients, such as access to their medical records.... ...
The case study by Elizabeth Layman (2011) is a very comprehensive compilation of the implementation of electronic health records, in relation to the Health Information Services Departments. Through this study Layman documents the conditions to be implemented to achieve satisfactory application of the change-over from the conventional pen and ledger system to computer documentation of patient’s records maintained by health networks.
Unfortunately, the quality of health care in America is flawed. Information technology (IT) offers the potential to address the industry’s most pressing dilemmas: care fragmentation, medical errors, and rising costs. The leading example of this is the electronic health record (EHR). An EHR, as explained by HealthIT.gov (n.d.), is a digital version of a patient’s paper chart. It includes, but is not limited to, medical history, diagnoses, medications, and treatment plans. The EHR, then, serves as a resource that aids clinicians in decision-making by providing comprehensive patient information.
When walking into a hospital, nursing home, or physician’s office, electronic devices are used everywhere. The doctors have pagers, drugs are released from an apparatus similar to vending machines, and the patients are connected to intravenous pumps and monitors, while they lay on beds that move with the touch of a button. Everything seems to be electronic, except for patient charts. A new system, called eHealth, was devised that would make these patient charts electronic. The goal for electronic health is to unite all healthcare by making patient records available to all providers in order to improve the quality of care patients receive. eHealth can be adopted into hospitals, physicians’ offices, and even ambulatory services. A 2006 study found, “Ambulatory EHRs improve the structure of care delivery, improve clinical processes, and enhance outcomes” (Shekelle 61). With professionals working together, procedures, scans, tests, and even visits to the hospital can be eliminated and in turn reduce the hospital’s expenses. However, this reduction may not add up to the investment the facilities will have to make. Adopting this system will cost more the some facilities are able to spend. However, investing in eHealth is a risk hospitals should take to improve patient care. eHealth has to become affordable to all providers for healthcare to reach its full potential.
An electronic health record (EHR), or electronic medical record (EMR), refers to the systematized collection of patient and population electronically-stored health information in a digital format. It details medical problems, medications, vital signs, patient history, immunizations, laboratory data and radiology reports, progress notes .These records can be shared across different health care settings. It resides on an enterprise information systems and is exchanged via electronic networks.EHRs may include a range of data, including demographics, medical history, medication and allergies, immunization status, laboratory test results, radiology images, vital signs, personal statistics like age and weight, and billing information.why is it needed? It seeks to be a complete record of a patient that can follow him/her from setting to setting increasing knowledge and consistency. It allows providers to obtain a complete picture of a patient and allows firms to automate and streamline workflows. It could improve patient and financial outcomes via evidence-based decisions, quality management, data mining, tracking, and reporting.
This paper will identify the use of Electronic Health Records and how nursing plays an important role. Emerging in the early 2000’s, utilizing Electronic Health Records have quickly become a part of normal practice. An EHR could help prevent dangerous medical mistakes, decrease in medical costs, and an overall improvement in medical care. Patients are often taking multiple medications, forget to mention important procedures/diagnoses to providers, and at times fail to follow up with providers. Maintaining an EHR could help tack data, identify patients who are due for preventative screenings and visits, monitor VS, & improve overall quality of care in a practice. Nurse informaticists play an important role in the adaptation, utilization, and functionality of an EHR. The impact the EHR could have on a general population is invaluable; therefore, it needs special attention from a trained professional.
The EHR is a computerized health record that will take place of the paper chart. The health care information will be available to all health care providers at anytime, anywhere. The record will contain medical history, diagnosis, medications, immunization, allergies, diagnostics and lab results; from past doctors, emergency department visits, school, pharmacies, and out patient laboratories and facilities (Department of health and human services, 2014). Health care providers will be able to access evidence-based tools to aid in decision-making. EHR will also streamline workflow, and support changes in payer requirements and consumer expectations. In 2004, “the HHS secretary, Tommy Thompson appointed David Brailer as the national health information coordinator to provide: leadership for the development and nationwide implementation of a interoperable HIT infrastructure, with the goal of establishing electronic health records...
In the 2004 State of the Union Address, President George W. Bush stated “within the next 10 years, Electronic Health Records (EHRs) will ensure that complete health care information is available for most Americans at the time and place of care (U.S. Government)”. In order to encourage the widespread implementation of EHRs and to overcome the financial barrier to doing so, the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 set aside $27 billion in incentives to be distributed over a ten-year period for hospitals and healthcare providers to adopt the meaningful use of EHRs (Encinosa, 2013). In 2011, the Centers for Medicaid and Medicare Services (CMS) implemented the Meaningful Use (MU) Incentive Program. In order to qualify for incentive payments under MU, providers must attest to meeting specific quality measures thresholds each year consisting of three stages with increasing requirement at each stage.
Electronic health records is medical information recorded on computers, the data consists of a variety of data, medical history, medication, allergies, diagnoses, immunizations, labs, radiology, vital signs, billing information, and personal statistics weight and age. The EHR is designed to help with medical errors. It helps reduce errors with allergies to a medication. Also help with reading legibility and eliminate the lost forms and paperwork. It allows for the patients history to be viewed by several doctors. Doctors or nurses can update information on your record.
Studies have implied that, healthcare professionals who practice clinical features through EHR were far more likely provide better preventive care than were healthcare professionals who did not. (page 116). From 2004, EHR has initiated, even the major priority of President Obama’s agenda is EHR (Madison & Stagger, 2011). Health care administration considers EHR as the introduction of advanced technology which can improve patient satisfaction are can increase the financial incentives of the healthcare organization. Studies have pointed out that the federal policy is proposed to transform all medical records into EHR (Hebda & Calderone, 2010).
The purpose of the Electronic Health Record is to provide a comprehensive, standardized and universal digital version of a patient 's health records. The availability of a patient 's digital health record provides health information and data for critical thinking and evidence based decision-making, aggregates patient data for quality assurance and research. The Electronic Health Record has been, "identified as a strategy for effectively and efficiently coordinating and maintaining documentation of patients health histories and as a secure method of providing more informed clinical decision making" (MNA, 2006).